Genitourinary trauma

Genitourinary trauma includes injury to the kidneys, ureters, bladder, urethra, and genitals, and is associated with a high level of morbidity if not properly identified and managed. Classic symptoms include abdominal pain and hematuria. Diagnosis is typically based on patient history, physical examination, urinalysis, and imaging (e.g., CT, cystoscopy, retrograde urethrography). Management is based on the type of injury and concomitant trauma. Unstable patients with genitourinary trauma may require emergency surgical interventions such as exploratory laparotomy. Renal trauma is most commonly caused by blunt abdominal trauma, and mild renal injuries can often be treated conservatively. Ureteral injuries are often iatrogenic and may require stent placement and/or surgical repair. Bladder injuries are common in blunt abdominal trauma, and treatment differs for intraperitoneal bladder rupture and extraperitoneal bladder rupture. Genital injury may be caused by blunt or penetrating trauma, including sexual assault. Treatment depends on the type and severity of genital injury. Complications of genitourinary trauma include urinary extravasation, urinoma, abscess formation, renal hypertension, and loss of function in the affected kidney.

Ensure evaluation contains the following components of the ATLS algorithm: ^[1]

Primary survey

• Perform FAST and consider portable chest and/or pelvic x-ray.
• Stabilize pelvic fractures with a pelvic binder.
• Treat hemorrhagic shock and prepare for exploratory laparotomy if indicated.
• See “Approach to penetrating abdominal trauma” and “Approach to blunt abdominal trauma” for more details.

Secondary survey ^[1][2]

Assess for features of genitourinary trauma and consult urology and/or trauma surgery for co-management of the patient.

• Inquire about high-risk injury mechanisms, e.g., straddle impact. ^[1]
• Examine the abdomen, flank, back, groin, and rectum for evidence of:
  • Back or flank contusions, hematomas, and ecchymoses, which can indicate renal injury
  • Genital injury (e.g., scrotal or vulvar hematoma)
  • Urethral injury (e.g., high-riding/nonpalpable prostate, blood at the urethral meatus)
  • Signs of peritonitis
• Send laboratory studies.
  • Urinalysis: may show hematuria; amount does not correlate with the extent of the injury.
  • CBC, BMP, type and screen, serum or urine β-hCG
• Obtain imaging unless there are urgent indications for emergency laparotomy.
  • General indications for imaging in GU trauma include:
    • Blunt and/or penetrating abdominal trauma
    • Penetrating back and/or flank trauma
    • Injury mechanism consistent with possible genitourinary trauma
  • Modalities: e.g., CT with IV contrast, retrograde urethrogram
  • For anatomically specific indications and modalities, see “Renal injuries”, “Ureteral injuries”, “Bladder injuries”, and “Urethral injuries.”
• Exclude urethral injury before urinary catheterization.

Tertiary survey

• Monitor for hematuria and signs of sepsis.
• Measure urine output and check for difficulty voiding.
• Monitor for complications of genitourinary trauma.

Always evaluate patients with pelvic fractures for possible injury to the genitourinary system.

If there is any evidence of urethral injury, obtain a retrograde urethrogram before placing a transurethral catheter.

Types of injuries ^[3][4]

• Renal laceration: a tear in kidney tissue; may lead to urinary extravasation and/or bleeding
• Renal hematoma: a collection of blood within the renal parenchyma
• Renal vascular injury: renal vein or artery injury leading to active bleeding, thrombosis, and/or devascularization
• Hilar avulsion injury: shearing of the renal hilum; can lead to complete devascularization and profuse bleeding

Etiology

• Blunt trauma (up to 95% of cases) ^[5]
  • Blunt abdominal trauma, e.g., acceleration/deceleration injury due to motor vehicle collisions or falls
  • Blunt thoracic trauma, e.g., blows to the torso: associated with lower rib (9^th–12^th) fractures ^[6]
• Penetrating trauma (e.g., gunshot or stab wounds)

Clinical features ^[2]

• Pain, bruising, hematoma on the affected side
• Hematuria
• Accompanying injuries (e.g., rib fracture)
• Hemorrhagic shock
• Abdominal distention or palpable mass

Diagnostics ^[2][3][5][7]

• Follow the approach to genitourinary trauma.
• If the patient is unstable, actively bleeding, and/or requires emergency surgery, perform an emergency preoperative evaluation.
• See “Urgent diagnostics for trauma patients” for a general list applicable to all trauma patients.

Laboratory studies

• Urinalysis: macroscopic hematuria or microscopic hematuria
  • The type or severity of hematuria does not correlate with injury type or severity.
  • Microscopic hematuria after significant nongenitourinary trauma is common.
• Creatinine: to establish baseline renal function ^[2]

Imaging

• Indications (in addition to general indications for imaging in GU trauma)
  • Gross hematuria after blunt trauma
  • Injury pattern consistent with possible renal injury (e.g., lower rib fractures, flank ecchymosis)
• Modalities and findings
  • CT with IV contrast of the abdomen/pelvis (gold standard)
    • To assess for renal and accompanying injuries or intraabdominal fluid retention
    • See “Classification” for imaging findings.
  • Delayed-phase CT imaging: to assess for injury to the renal pelvis and/or ureters

Classification ^[4]

Based on imaging findings, renal injuries are usually classified using the American Association for the Surgery of Trauma (AAST) grading system for traumatic renal injury.

• Low-grade renal injuries (grade I–III)
  • Subcapsular or perirenal hematoma within Gerota fascia
  • Renal laceration without urinary extravasation or vascular injury
• High-grade renal injuries (grade IV–V)
  • Vascular injury with active bleeding or devascularization
  • Renal and ureteropelvic injuries with urinary extravasation
  • Avulsion of the renal hilum
  • Unidentifiable renal anatomy (shattered kidney)

Treatment ^[5][7][8]

Hemodynamically unstable patients

• IV fluid resuscitation and emergency transfusion if necessary
• Initiate urgent intervention: exploratory laparotomy or angioembolization (for selected patients) ^[5]

Hemodynamically stable patients

• Admit for observation with hemodynamic monitoring, bed rest, and supportive care.
• Serial laboratory studies
• Ensure adequate urinary drainage (e.g., ureteral stent placement, percutaneous drainage).
• Consider angioembolization for bleeding in consultation with urology.
• Re-imaging in cases of clinical deterioration and high-grade injuries

Disposition ^[2]

• Determine disposition in consultation with trauma surgery and urology.
• Admit patients with renal injuries for observation.

Types of injuries ^[3][9]

• Ureteral laceration: injury of the ureter with incomplete transection; ranges from pinpoint defects to large openings
• Ureteral avulsion
  • Traumatic shearing of the ureter causing ureteral discontinuity
  • Can occur during ureteroscopy, most commonly due to instruments that are too large for the ureter or attempted removal of insufficiently fragmented stones ^[10]
• Others: complete transection, hematoma, or contusion, ligation or thermal injury

Etiology ^[3]

• Most common: iatrogenic (e.g., ureteral avulsion during ureteroscopy, intraoperative ureteral laceration or ligation) ^[3]
• Penetrating trauma (e.g., gunshot or stab wounds)
• Blunt abdominal trauma (e.g., deceleration injuries, blows to the torso, pelvic fractures) ^[11]

Clinical features ^[2]

Nonspecific as they often occur with multisystem injuries

• Features of genitourinary trauma, e.g., hematuria
• Features of sepsis (due to urinary extravasation)
• Features of commonly associated injuries, e.g., vertebral fractures, pelvic fractures

Maintain a high level of suspicion for ureteral injuries in patients with high-energy blunt trauma or penetrating abdominal trauma as they are often overlooked. ^[11]

Diagnostics ^[2][7][11]

• Follow the approach to genitourinary trauma.
• If the patient is unstable, actively bleeding, and/or requires emergency surgery, perform an emergency preoperative evaluation.
• See “Urgent diagnostics for trauma patients” for a general list applicable to all trauma patients.

Laboratory studies

Urinalysis may show hematuria, which is an unreliable indicator of injury.

Imaging

• Indications (in addition to general indications for imaging in GU trauma)
  • Evidence of injury adjacent to the ureter (e.g., pelvic or vertebral fractures)
  • Clinical suspicion for ureteral injury (e.g., continued unexplained hematuria)
• Modalities and findings
  • CT abdomen and pelvis with IV contrast and delayed-phase imaging (CT urography; gold standard) may show:
    • Signs of extravasation (e.g., perirenal stranding, retroperitoneal fluid)
    • Signs of obstruction (e.g., hydronephrosis, delayed pyelogram)
  • Retrograde urethrography: for diagnostic confirmation if CT is equivocal

Treatment ^[2][7][11]

• Uncomplicated ureteral injury
  • Examples: contusion or hematoma of the ureter, ureteral laceration with incomplete transection
  • Retrograde (cystoscopic) ureteral stent placement with or without percutaneous nephrostomy
  • If laparotomy is indicated for other injuries, ureteral repair may be performed at the same time.
• Complicated ureteral injuries
  • Examples: ureteral laceration with complete transection, ureteral avulsion
  • Surgical repair (e.g., ureteroureterostomy, ureteral reimplantation) and stent placement
  • If surgical repair is not possible during primary surgery: ureteral ligation, urinary diversion (e.g., percutaneous nephrostomy), and delayed ureteral reconstruction

Disposition ^[2]

• Determine disposition in consultation with trauma surgery and urology.
• Most patients with ureteral injury require admission for intervention.

Types of injuries ^[9][11]

• Bladder contusion: intramural hematoma
• Bladder laceration: partial-thickness injury of the bladder wall
• Bladder rupture: full-thickness injury of the bladder wall
  • Extraperitoneal bladder rupture with urine accumulation in the retropubic space
  • Intraperitoneal bladder rupture with intraperitoneal accumulation of urine
• Bladder neck avulsion: traumatic shearing of the bladder neck

Etiology ^[9][11]

• Blunt abdominal trauma: direct trauma to a distended bladder → increased intravesical pressure → bladder rupture, which is often intraperitoneal
• Pelvic fractures → pelvic bone fragments → extraperitoneal rupture of the anterior or anterolateral wall of the bladder
• Penetrating trauma
• Iatrogenic: transurethral or pelvic surgery

Clinical features ^[2][11]

• Gross hematuria (most patients)
• Inability to void, reduced urine output
• Lower abdominal pain, tenderness, or distention
• Blood at the urethral meatus
• Ecchymosis over the abdomen

Diagnostics ^[2][7][11]

• Follow the approach to genitourinary trauma.
• If the patient is unstable, actively bleeding, and/or requires emergency surgery, perform an emergency preoperative evaluation.
• See “Urgent diagnostics for trauma patients” for a general list applicable to all trauma patients.

Laboratory studies

• Urinalysis: likely to show hematuria
• Serum creatinine and BUN: may be elevated due to peritoneal resorption of urinary creatinine ^[12]
• Laboratory evaluation is otherwise not useful for diagnosing bladder injuries.

Imaging ^[3][7][13]

Indications

In addition to general indications for imaging in GU trauma:

• Gross hematuria with pelvic fracture
• Presence of other features of bladder injury (see “Clinical features”)
• High-risk fracture patterns: e.g., pubic symphysis diastasis, pubic rami fractures

Modalities and findings

CT pelvis with IV contrast is generally insufficient for evaluation of bladder injury.

• Modalities of choice
  • Retrograde cystography
  • Retrograde CT cystography
    • Has greater sensitivity than conventional cystography
    • Postvoid images are not required to identify bladder rupture.
• Findings: contrast extravasation

Avoid cystography if pelvic vascular injury is suspected, as extravasated contrast may obscure CT or angiography, as well as prevent potentially necessary embolization of bladder arteries. ^[11]

In retrograde cystography, approximately 10% of bladder injuries are only visible on postvoid x-ray images. ^[13]

Treatment ^[3][7][11]

• Bladder contusion: observation only
• Intraperitoneal bladder injury: surgical exploration and repair
• Extraperitoneal bladder injury
  • Uncomplicated
    • Insertion of a transurethral indwelling catheter or suprapubic catheter
    • Clinical observation
    • Consider prophylactic antibiotics. ^[14]
  • Complicated (e.g., bladder neck injury, associated pelvic ring fracture, or vaginal/rectal injury): surgical exploration and repair

In hemodynamically unstable patients, a urethral or suprapubic catheter can be inserted and definitive treatment of bladder injury delayed until the patient is stabilized. ^[11]

Disposition ^[2][3][11]

• Determine disposition in consultation with trauma surgery and urology.
• Most patients with bladder injury require admission for surgical intervention, bladder drainage, and/or monitoring.

Epidemiology ^[11]

Almost exclusively affects men, who have longer and less mobile urethras than women.

Common clinical features ^[2][11]

• Blood at the urethral meatus, initial hematuria, and difficulty voiding
• Palpable distended bladder due to inability to void despite urge
• Suprapubic pain

Anterior urethral injury ^[2][11]

Injury to the anterior urethra, which lies within the corpus spongiosum and consists of the bulbous and pendulous urethra

• Etiology
  • Direct trauma to the perineum (direct blow, straddle injury): bulbar urethra is commonly injured, leading to scrotal hematoma
  • Occurs in conjunction with penile fracture
  • Iatrogenic (e.g., urethral instrumentation)
  • Penetrating injury
• Specific clinical features
  • Scrotal hematoma
  • Normal prostate
  • Perineal tenderness and hematoma

Posterior urethral injury ^[2][11]

Injury to the posterior urethra, which extends from the neck of the bladder to the distal part of the urogenital diaphragm

• Etiology: associated with significant pelvic fracture due to trauma (e.g., motor vehicle collision); bulbomembranous junction is commonly injured
• Specific clinical features: high-riding prostate

Diagnostics ^[2][3][11]

• Follow the approach to genitourinary trauma.
• If the patient is unstable, actively bleeding, and/or requires emergency surgery, perform an emergency preoperative evaluation.
• Examine the rectal and genital area in patients with known or suspected urethral injury, because associated injury is likely.
• See “Urgent diagnostics for trauma patients” for a general list applicable to all trauma patients.

In hemodynamically unstable trauma patients with suspected urethral injury, consider placing a suprapubic catheter and postponing further evaluation for urethral injury until the patient is stabilized. ^[11]

Retrograde urethrography

• Indication: : all patients with suspected urethral injuries (gold standard) ^[11]
• Findings: contrast extravasation from the urethra at the point of injury ; ^[15]
  • Anterior injury
    • Superficial perineal space (with Buck fascia rupture)
    • Scrotum
    • Around the penis
    • Lower abdominal wall
  • Posterior injury
    • Deep perineal space
    • Retropubic space
    • Around the bladder and prostate

Obtain a retrograde urethrogram before catheterization to rule out suspected urethral injury.

Additional diagnostic studies

• Urethroscopy: alternative to urethrography in female patients and those with concomitant penile injuries
• MRI pelvis: may be used for surgical planning ^[16]

Treatment

Bladder drainage ^[2][3][11]

Bladder drainage should be performed as soon as possible and, once established, surgical management may be delayed for treatment of life-threatening injuries. ^[2]

• Transurethral catheterization
  • Suspected urethral injury is a relative contraindication for transurethral catheterization, as it may worsen the injury.
  • A single attempt at transurethral Foley catheterization may be made by an experienced provider.
  • Discontinue the attempt and place a suprapubic catheter if there is any resistance or difficulty.
• Suprapubic catheterization
  • Appropriate for patients with hemodynamic instability or contrast extravasation on retrograde urethrogram, or if transurethral catheter placement is unsuccessful
  • May be performed under direct visualization or ultrasound guidance

Definitive management ^[2][3][11]

• Blunt trauma: bladder drainage and delayed repair
• Penetrating trauma: immediate surgical repair (unless other life-threatening injuries are present)
• Penile fracture with urethral injury: concurrent urethral and penile repair

Disposition ^[2]

• Determine disposition in consultation with trauma surgery and urology.
• Patients generally require admission or transfer to a tertiary center for urgent evaluation by urology.

Penile fracture

See “Penile fracture” for details.

Scrotal injuries ^{[2][3][7][14][17]}

Types of scrotal injuries include testicular dislocation, testicular rupture, and scrotal hematocele.

Etiology

• Blunt trauma (e.g., direct blow, sports injury, motor vehicle collisions, straddle injury)
• Penetrating trauma (e.g., gunshot wound)
• Physical or sexual violence

Clinical features

Physical examination is often limited because of pain and swelling; imaging is usually necessary.

• Scrotal pain, swelling, and/or tenderness
• Ecchymosis
• Hematoma or hematocele
• Lacerations

Diagnostics

Follow the approach to genitourinary trauma.

• Scrotal ultrasound: preferred initial study
  • May be used to assess for testicular fracture, ruptures, hematoma, contusions, and inadequate perfusion
  • Findings: irregular or absent testicular contour, discontinuity of the tunica albuginea, heterogeneous echotexture
• MRI pelvis: only if ultrasound is not feasible

Treatment

• Penetrating injuries, testicular rupture, or testicular fractures (confirmed or suspected)
  • Surgical exploration and repair
  • Orchiectomy if testicle is not viable
• Testicular dislocation: manual reduction and orchidopexy
• Scrotal hematoma or hematocele
  • Small hematoceles or nonexpanding hematomas: conservative management (e.g., scrotal support, ice)
  • Large hematoceles or hematoma: evacuation and hemostasis

Consult urology urgently for definitive treatment, as early repair is associated with improved outcomes, including preservation of fertility and hormonal function. ^[17]

Vulvar and vaginal injuries ^{[3][14][18][19]}

Etiology

• Straddle injury
• Blunt trauma (e.g., direct blow)
• Penetrating trauma
• Physical or sexual violence
• Obstetric injuries (e.g., perineal lacerations)

Clinical features

• Swelling
• Pain
• Hematoma
• Lacerations or tears

Maintain a low threshold to perform clinical examination of the genitalia under procedural sedation, especially in pediatric patients. ^[2]

Diagnostics

• Follow the approach to genitourinary trauma.
• Vulvar and vaginal injuries are clinical diagnoses.
• Maintain a high level of suspicion for vulvar or vaginal injury if suggested by patient history. ^[19][20]
• Evaluate for concurrent soft tissue (e.g., urethral, anal) or bony injury.
• Assess for sexual violence red flags and consider additional diagnostics for sexual violence as indicated.

If sexual violence is suspected, coordinate the work-up including gynecological examination with a sexual assault nurse examiner.

Check for retained devices/objects in the vagina (e.g., tampons) to reduce the risk of sepsis and/or toxic shock syndrome. ^[21]

Treatment

Consider gynecology and/or trauma consultation for complex (e.g., penetrating) or multisystem injuries and initiate management of recent sexual violence as necessary.

• Lacerations: primary repair (see “Wound management” and “Perineal lacerations” for details)
• Most hematomas: conservative therapy (e.g., rest, ice, compression, primary wound closure) with urinary catheter placement if necessary
• Expanding or large (> 4 cm) hematomas may require surgical drainage. ^[18]

• Early
  • Bleeding
  • Infection, abscess
  • Urinary extravasation, urinoma (a cyst containing urine that forms outside the urinary tract following trauma or surgery)
  • Renal hypertension
• Late
  • Bleeding
  • Hydronephrosis
  • Calculus formation
  • Chronic pyelonephritis
  • Hypertension
  • Arteriovenous fistula
  • Urethral stricture
  • Urinary incontinence
  • Sexual dysfunction
  • Loss of function in the affected kidney resulting from hydronephrosis or renal artery stenosis

We list the most important complications. The selection is not exhaustive.